From: hounddog23x@gmail.com   
      
   OIG HHS   
      
   Newsroom    
      
   Spotlight On...   
   Fighting Fraud at Community Mental Health Centers   
      
   Lethal Weapon. Tootsie. Ghostbusters. Batman. You may think these are great   
   movies--some might argue they're classics--but do they qualify as   
   psychotherapy? Patients at Diagnostic and Behavioral Health Clinic watched   
   these films for entertainment and    
   participated in other recreational activities, such as playing games and going   
   on field trips, while the clinic billed Medicare for mental health services.   
   Therapists also charged for 1-hour sessions when patients were in-and-out the   
   door in 15 minutes.    
   As a result, the clinic improperly billed Medicare over $4 million. OIG's   
   investigation of this case led to the 1999 convictions of the owner and   
   another employee.   
   Over a decade later, OIG and our law enforcement partners found that employees   
   at another   
   facility--American Therapeutic Corporation External link--concocted a $205   
   million fraud scheme involving fictitious companies, fabricated patient files,   
   patient recruiters, kickbacks, and elaborate cover-ups. They also illegally   
   prescribed unnecessary    
   psychotropic medications. Prosecutors for the case charged dozens, and the   
   three owners/operators received a combined 120 years in prison (additional   
   information below).   
   Besides committing fraud, the facilities in these two examples have something   
   else in common: both are Community Mental Health Centers (CMHC), a type of   
   facility that provides mental health services to individuals who reside in a   
   defined geographic area.    
   Fraud at CMHCs is not new, and OIG studies on CMHCs show that it isn't   
   isolated. For example, the report Questionable Billing by Community Health   
   Centers found approximately half of CMHCs had unusually high billing for at   
   least one of nine questionable    
   billing characteristics. These characteristics include billing for patients   
   with no mental health diagnoses, billing for patients who participated in   
   CMHCs outside their own communities, or billing for patients who were not   
   referred by health care    
   facilities. While there are procedures in place for detecting and deterring   
   fraud involving CMHCs, another OIG report - Vulnerabilities in CMS's and   
   Contractors' Activities to Detect and Deter Fraud in Community Mental Health   
   Centers - identified a    
   number of shortcomings in oversight of CMHCs and found the extent to which   
   Medicare contractors engaged in anti-fraud activities varied considerably.   
   A map of fraud-prone areas   
   However, through programmatic recommendations, data analytics, and   
   geographically targeted fraud-fighting efforts, OIG and partners have made   
   significant progress cracking down on CMHC fraud. For example, an October 2013   
   final rule on CMHCs External link    
   cited findings from OIG's Questionable Billing report and enacted our   
   recommendation to finalize CMHC conditions for participation in Medicare.   
   Furthermore, by analyzing payment trends, OIG agents determined the areas   
   where suspicious billing by CMHCs is    
   most rampant. As shown in Figure 1, our principal target areas - known as   
   Strike Force cities - overlap with the cities identified in OIG's report as   
   home to approximately two-thirds of the CMHCs with questionable billing. We   
   deployed our Strike Force    
   teams to investigate CMHCs with excessive Medicare billing and prosecute   
   fraud. This focused law enforcement crackdown sent fraudsters to jail and sent   
   the message that CMHC fraud will not be tolerated.   
   A graph of medicare payments for CMHCs by calendar year   
   And the data suggests this message made an impact. Total national Medicare   
   payments to CMHCs peaked in 2008 at $273 million. Targeted enforcement   
   activities - centered in Miami, Baton Rouge, and Houston - also began in 2008,   
   and major enforcement actions    
   occurred in all three cities from 2010 - 2012, some of which are described   
   below. As seen on the graph, payments to CMHCs dramatically decreased during   
   and after this period. In 2012, payment levels fell to $31 million, a   
   difference of over $240 million.    
   This may suggest that the large-scale CMHC fraud convictions not only   
   eliminated some of the "bad actors" but could have also deterred other   
   "would-be" fraudsters.   
   Our CMHC work is a clear example of how devoting resources to fraud-fighting   
   can pay off. But it's also important to consider the challenges that still   
   exist. For example, while billing dramatically decreased in the targeted   
   areas, criminals may have    
   moved into other types of fraud. Furthermore, OIG investigations continue to   
   identify scenarios where CMHCs bill for mental health services but instead   
   provide, at best, recreational adult day care. This not only clogs the system   
   for those in need of    
   legitimate care, but could also drive up overall health care costs. As mental   
   health services are expanding under the Affordable Care Act, the task of   
   rooting out fraud, waste, and abuse will only become more vital. Therefore,   
   OIG will continue to use    
   every tool in its arsenal - inspections, audits*, data-analytics, law   
   enforcement partnerships, and more - to fight fraud and protect Medicare   
   mental health services.   
   *OIG is currently reviewing the appropriateness of Medicare payments for   
   partial hospitalization program psychiatric services in hospital outpatient   
   departments and community mental health centers. For more information on this   
   upcoming audit, see page 22    
   of our 2013 work plan.   
   CMHC Fraud Cases in Strike Force Cities   
      
   [continued in next message]   
      
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    * Origin: you cannot sedate... all the things you hate (1:229/2)